Ultrasound Training

Abdominal Aortic Aneurysm Screening

4-5% of sudden deaths; Prevalence = 4-9% of people > 60 YO
Mortality approaches 80%
>90% mortality if AAA rupture occurs outside of the hospital
Classic Triad of pain, hypotension, and pulsatile mass (occurs in <50% of cases)
Many patients are misdiagnosed initially because they present with vague back pain.
Methods for detection: physical exam (low sensitivity), ultrasound (very sensitive and
very specific), and CT (gold standard better than ultrasound for ruptured AAA and for
dissections, but they are expensive and can cause kidney injury due to contrast
exposure)
USPSTF recommends one-time screening for AAA with ultrasonography in men ages 65-
75 who have ever smoked (Level B)
AAA Definition: aneurysm 3 cm
o If AAA is 3-4 cm, they should have annual follow-up exam
o If AAA is 4-4.5 cm, they should have f/u every 6 months
o If AAA is >4.5 cm, they should have immediate referral to vascular surgery
o If AAA 5.5 cm emergency situation
2012 study found that AAA screening can be safely performed in the family medicine
office by physicians who are trained to use point-of-care ultrasound
What to determine when performing the scan:
o 2 questions to ask
Is the abdominal aorta > 3 cm in diameter?
Are the ileac arteries > 1.5 cm in diameter?
o Views to perform:
Transverse view of proximal aorta
Transverse view of the mid aorta
Transverse view of the distal aorta
Transverse view of the distal aorta showing the bifurcation in both iliacs
Longitudinal/sagittal view of the aorta
o Scanning
Use the curvilinear probe
Start proximally under the xiphoid area with the indicator on the right
Identifying the aorta in the transverse view (Proximal)
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Identifying the aorta in the transverse view (MID)

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Identifying the aorta in the transverse view (Distal)

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Identifying the aorta in the longitudinal view
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Ultrasound of patient with AAA

Lower Extremity DVT Ultrasound

When you encounter a patient with a swollen leg (unilateral or bilateral), the differential
is always going to include a blood clot. In general, you want to differentiate cellulitis,
DVT, CHF, and venous insufficiency.
Using bedside ultrasound, it takes ~3.5 minutes to evaluate 2-3 points.
Use the linear probe because veins are superficial. Rarely, you may use the curvilinear
probe if the patient is obese and you cant penetrate enough with the linear probe.
The indicator should be pointed towards the patients right side.
Positioning the patient: when you frogleg the patient (external rotation of the hip,
flexion of the knee), you increase the femoral vein size by 2 mm and you decrease the
vein depth by 2 mm.
 Location: scan around the middle of the inguinal canal, which is where the common
femoral vein is located. Put get across the entire leg. Slide down to the superficial
femoral vein. Finish by scanning the popliteal vein.

o
Proximal DVT: blood clot located proximal to the popliteal vein.
Techniques that can be used: color Doppler, augmentation, and compression (use this)

Color Doppler

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Augmentation
o You augment by squeezing the calf and producing blood flow back towards the
heart, which allows you to detect flow to the vein.
o Adverse Effect: you can dislodge a clot

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Compression
o 1989 study published in the NEJM found that if you only use vein compression,
there is 100% sensitivity for a proximal DVT
 o 1997 study found that color Doppler did not detect any additional proximal/calf
DVT compared to regular compression
o How much compression is needed?
Notice the artery located up and to the left of the vein that you are
compressing. Apply enough pressure so that the artery begins to indent a
little.

Sequence

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Abnormal Scans
o Common Femoral Vein clots


o Clot with color flow

o Clot at the junction of the CFV (middle) and the saphenous vein (top right)


o Clot at the Superficial Femoral Vein (also note that the SFV is non-compressible
compared to the vein above it on the image)

Thyroid Ultrasound: Evaluation of a thyroid nodule
Background
o The main indication for a thyroid US scan is for the evaluation of a new thyroid
nodule
o Thyroid carcinoma is the most frequent type of endocrine scan in the United
states, but only accounts for 0.5% of cancer deaths
o The majority of nodules are benign
o 50% of patients with clinically normal thyroids had nodules at autopsy
o Nodule detection by physical exam 1 cm; Nodule detection by ultrasound 1
mm
How to perform the scan:
o Use the linear probe because the thyroid is superficial
o Patient should be supine with their neck extended
o Indicator to the right when in the transverse plane and towards the head when in
the longitudinal plane
o Start the scan with the probe just above the sternal notch.
Basic anatomy
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Benign vs Malignant Features
o Normal thyroid tissue has a one homogenous, medium-level echogenicity

o Example of a nodule

o Determining malignancy
There are NO characteristics that are diagnostic for benign or malignant
nodules.
Characteristics associated with benign nodules
 Anechoic or hyperechoic
Peripheral calcification
Positive halo sign
Heterogeneous composition
Peripheral vascularization
< 1 cm size
Characteristics associated with malignant nodules
Hypoechoic
Punctate microcalcifications
Absent halo sign
Solid composition
Intranodal vascularization
> 2 cm size
According to a 2013 study published by JAMA Intern Med, the top three
indicators of malignancy are microcalcifications, nodule size greater than
2 cm, and an entirely solid composition of the nodule.
o Echogenicity

o Microcalcifications

o Halo Sign (hypoechoic or anechoic rim surrounding the nodule; its presence
suggests the nodule is benign)

o Composition
If the nodule is completely solid malignant


o Vascularity
Peripheral vascularity benign
Intranodal vascularity malignant
Use the Color Doppler to visualize